Broader Health System Research Articles

Costs and economic impact of student-led clinics-A systematic review.

Student-led clinics generate a range of benefits to multiple stakeholder groups. Students receive important educational opportunities to advance in their training. Patients with limited access to care may access effective care or a higher amount of effective care and so reduce burden on the health care system. The financial viability of student-led clinics run by universities is uncertain, and establishing this is complicated by the range of stakeholder costs and benefits that may be involved. This systematic review aimed to synthesise evidence related to the costs and benefits of student-led clinics and report the methods that have been used to measure these costs and benefits. We conducted a systematic search of MEDLINE All, PsychInfo, CINAHL, A+ Education (Informit), ERIC (ProQuest) and ProQuest Education databases for studies that reported the costs and/or economic benefits of student-led clinics from inception through August 2023. Studies were screened for eligibility, and data were extracted including study characteristics, student-led clinic description and economic outcomes. A narrative synthesis was undertaken due to the heterogeneity of studies. Of 349 potentially eligible studies, 24 were included. Nine studies (38%) used an outcome description-monetised approach; four used partial economic evaluation (17%); four employed cost description (17%); two used cost approximation (8%); two used cost analyses (8%); and one was a full economic analysis (4%). Studies examined costs or benefits, from the perspective of a range of stakeholders, but few examined both. Only six studies (25%) had established the clinical effectiveness of their service. Student clinics generate costs for universities in supplying supervision, capital and consumables. Benefits are shared by patients, students, universities and the broader health system, however, economic evaluations to date have largely ignored or not monetised/valued these benefits. Student-led clinics involve many different stakeholders, each of whom may incur costs and reap benefits. This complicates how we can go about trying to establish the economic efficiency and viability of student-led clinics. Measurement of both costs and benefits is needed to understand the efficiency of student-led clinics in comparison to alternatives. Without the full picture, decision-makers may make decisions that are ill-informed and lead to a loss of benefit for society.

Fragmentation of payment systems: an in-depth qualitative study of stakeholders’ experiences with the neonatal intensive care payment system in Iran

BackgroundIran’s fee-for-service (FFS) payment model in neonatal intensive care units (NICUs) is contentious due to the involvement of multiple stakeholders with differing interests, leading to increased costs, fragmentation, and reduced quality of care. This study explores the experiences and challenges of stakeholders with the NICU payment system and considers alternative payment methods.MethodA qualitative research approach was used, involving key informant interviews with stakeholders at various levels of the health system. Data were collected between March 2022 to September 2023 using a purposive sampling method with a snowball strategy. The transcribed data were analyzed using an inductive thematic approach in MAXQDA, with themes and sub-themes emerged and assessed by two independent coders. Four trustworthiness criteria were applied to ensure the quality of the results.ResultsThe study involved 23 participants with diverse NICU payment backgrounds, identifying issues related to service accessibility, rising costs, neonatologists’ income, and service quality. Stakeholders held differing views on the best payment model: health insurance executives favored a prospective payment method, faculty members favored supported modified FFS or per diem, and neonatal specialists expressed concerns about low tariffs and delayed payments.ConclusionIran’s NICU payment system is unsatisfactory and requires urgent reform. Although stakeholders disagree on the best approach, reforms must be evidence-based and collaborative, addressing structural and cultural issues within the health system. The identification of an optimal payment system is essential for supporting neonatal care, benefiting newborns, families, society, and the broader health system.

Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast

BackgroundHealth system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal.MethodsOur analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa’s power cube and Long’s actor interface analysis.ResultsWe observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs’ and SCHMTs’ capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents.ConclusionOur findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required.

The intersection of TB and health financing: defining needs and opportunities

TB is an airborne public health threat, so the reponse to TB has been defined mainly through the lens of vertical, public-sector national TB programs (NTPs). However, TB exists within a broader health systems and health financing context. Here, we examine the intersection between the particular needs of TB programs and the broader health financing landscape. This includes the strategies needed to finance both the clinical and public health aspects of the TB response. In high-burden countries, the resource mobilization and strategic purchasing approaches described here will be critical if we are to maximize the reach and impact of the TB response.

'The Lost Peace': Evidencing the Syndemic Relationship between Neglected Tropical Diseases and Mental Distress in Liberia.

Neglected Tropical Diseases (NTDs) are a group of chronic infectious diseases of poverty affecting over one billion people globally. Intersections of NTDs, disability, and mental ill-health are increasingly evidenced but are rarely studied from a mixed-methods perspective. Here, we advance syndemic understandings by further assessing and contextualising the syndemic relationship between NTDs (particularly their associated disability) and mental distress in Liberia. Participatory qualitative methods, including body mapping (56 participants), social mapping (28 participants), and in-depth interviews (12) provided space for persons affected by NTDs to narrate their experiences. Simultaneously, 201 surveys explored experiences of common mental health conditions among persons affected by skin NTDs. An intersectionality approach was applied within the analysis for both qualitative and quantitative methods informed by Meyer's minority stress model, adapted for NTDs. Qualitative data was analysed thematically and gender-disaggregated, univariable and multivariable analyses were applied to survey data for the outcome measures depression (PHQ-9) and anxiety (GAD-7). Disability was associated with higher levels of depression and anxiety (p < 0.001). An interaction between disability and being a women increased incidence risk ratio of depression (p < 0.001). In alignment with qualitative findings, persons affected experienced additional generalised (financial concerns), external (experience of stigma) and internal (experience of pain and physical symptoms) minority stressors, to varying degrees, which contributed towards their mental distress, and mental health conditions. These findings were used to co-develop a syndemic-informed person-centred health system response to address the suffering associated with NTDs and mental distress, including a focus on strengthening relationships between formal and informal community health actors and the broader health system.

Telemedicine in Italy: Healthcare authorization profiles in the modern medico-legal reading.

The ruling n. 38485, 20 June 2019, of the Italian Supreme Court, III criminal section, addressed by the perspective of the law the very sensitive and new issue of telemedicine. This commentary deals with the issue of authorization of telemedicine activities by the health authority, starting from the Italian Court of Criminal Cassation, III section, decision n. 38485/2019. The case law explored the authorization of a health point, which carries out telemedicine services. Starting from the perspective discussed by Italian health regulations, the paper examines how the health act could be defined, with the possibilities offered by telecommunications, and how it now relates legally to the physical place where it takes place. Even if telemedicine opens the way to virtual spaces of health practice, the Ministry of Health Italian Guidelines pose functional and logistical issues to guarantee users' safety and health care system accountability. Then, functional requirements for health legitimate practice, and their continuous monitoring, together with the responsibilities of the service centers, health professionals and health facilities, are discussed. The questioning of States' health law, in a broad health system such as that of the Europe, characterized by autonomous health regulations, is extremely important for cross-border health policy with telemedicine, as overall regulatory compliance in health care is the ground criterion for risk prevention and patient safety, to be properly verified.

Sustaining village malaria worker programmes with expanded roles: Perspectives of communities, healthcare workers, policymakers, and implementers in Vietnam.

In Vietnam, multiple types of community-based malaria workers are recruited to promote access to malaria testing and treatment for at-risk mobile and migrant populations. However, as the country approaches elimination, these roles are at risk from declining investment. This article characterises the different types of workers and relevant health policy in Vietnam, and explores stakeholder perspectives on sustaining and expanding the roles of these workers in the malaria elimination context. We conducted a rapid policy document review to describe the policy background of community-based health care in Vietnam and identify key informants. In-depth interviews were conducted with policymakers and implementers (n = 11) in different government sectors, international, and civil society organizations. We also conducted interviews (n = 8) and two focus group discussions with community members (n = 12), and interviews with health workers (n = 9) in 18 communities in Phu Yen and Binh Thuan provinces in the central region. Our study identified three main types of malaria workers: village health workers (VHWs), malaria post workers (MPWs) and other groups of workers supported by civil society organisations (CSO). Workers reported being willing to maintain their current roles and potentially provide additional services that respond to community needs, although they were concerned about excess workload and inadequate income. Besides working in a variety of jobs to secure their incomes, mainly in agriculture, VHWs in particular were primarily tasked with supporting the delivery of a wide range of health services from commune health stations. Faced with reduced patients, MPWs and CSO-supported workers could be tasked with the following potential roles: case notification for infectious diseases, real-time data collection and reporting, and screening for non-malaria illnesses using other rapid test kits. There was agreement that the community-based health network is crucial to health care delivery in remote communities and to ensure comprehensive access to care among vulnerable populations. However, policymakers and implementers stressed concerns about their limited skillsets, the inadequate budget to support these workers, and the regulation constraining them from performing diagnosis and treatment activities, highlighting the priority to maintain the capacity of workers and funding allocation through provincial advocacy and multi-programme collaboration. This study highlights the crucial role of community-based health workers in eliminating malaria in Vietnam. Sustained efforts are needed to maintain accessible case detection and treatment while addressing local health concerns beyond malaria. Implementing these strategies requires prioritizing the mapping of groups most in need and developing enablers to raise community awareness and maintain the capacity of these workers. Ensuring political advocacy, financial resources, and coordination between multiple groups are key to maximizing impact and integrating malaria activities into the broader health system.

ASSESSMENT OF TÜRKİYE'S PROVINCES WITH HEALTH INFRASTRUCTURE INDICATORS USING DESCRIPTIVE ANALYSIS AND HEALTH INDEX

Health systems assessment is critical to ensure the sustainability of health services. The interest of researchers in analysing health systems, which intensified during the pandemic, is motivated by the opportunity to identify weaknesses and propose changes. Health systems analyses provide valuable feedback for policy makers, especially in developing countries, which struggle with obstacles such as limited resources, financial constraints and deficiencies in health infrastructure. As a developing country, Türkiye has been striving to ensure equal access to health services through its health transformation programme. In the last decade, developments such as the increase in Syrian migrants and economic contraction have negatively affected this effort. This situation motivates the need to analyse the current situation in the Turkish health system and provide suggestions for improvement. The literature on the Turkish health system mostly focuses on broad health system indicators such as health service accessibility, efficiency, quality and user satisfaction. This study focuses on assessing the accessibility of health infrastructure resources. In the study, health infrastructure indicators related to the Turkish health system are evaluated on a province basis for the period from 2012 to 2021. The evaluation is based on the descriptive statistics of the dataset and the province-based health index. The findings show changing trends and gaps in access to health services with the increase in population in the period 2012-2021. Some variables (e.g. population per hospital and population per bed) show low variances, while others (e.g. population per intensive care bed) show large differences. These differences may indicate unequal development and investment in health infrastructure. For policy makers, they emphasise the need to develop policies to address these inequalities and to distribute resources equitably. Analysing the health index values shows inequalities in access to health resources in different provinces of Türkiye as a score. In particular, while some provinces such as Isparta and Bolu stand out with consistently high index scores, lower index scores in other provinces such as Şanlıurfa, Mardin, Ağrı and Şırnak indicate that inequalities in access to health services are faced. This index identifies changes and gaps in the distribution of health resources and shows policy makers priority areas for intervention.

Defining a malaria diagnostic pathway from innovation to adoption: Stakeholder perspectives on data and evidence gaps.

Malaria, a major global health concern, requires effective diagnostic tools for patient care, disease control, and elimination. The pathway from concept to the adoption of diagnostic products is complex, involving multiple steps and stakeholders. To map this process, our study introduces a malaria-specific diagnostic pathway, synthesising existing frameworks with expert insights. Comprising six major stages and 31 related activities, the pathway retains the core stages from existing frameworks and integrates essential malaria diagnostic activities, such as WHO prequalification processes, global stakeholder involvement, and broader health systems considerations. To understand the scope and availability of evidence guiding the activities along this pathway, we conducted an online survey with 113 participants from various stages of the malaria diagnostic pathway. The survey assessed perceptions on four critical attributes of evidence: clear requirements, alignment with user needs, accuracy and reliability, and public and free availability. It also explored the types of evidence used and the challenges and potential solutions related to evidence generation and use. Respondents reported using a broad range of formal and informal data sources. Findings indicated differing levels of agreement on the attributes across pathway stages, with notable challenges in the Approvals and Manufacturing stage and consistent concerns regarding the public availability of data/evidence. The study offers valuable insights for optimising evidence generation and utilisation across the malaria diagnostic pathway. It highlights the need for enhanced stakeholder collaboration, improved data availability, and increased funding to support effective evidence generation, sharing, and use. We propose actionable solutions, including the use of public data repositories, progressive data sharing policies, open-access publishing, capacity-building initiatives, stakeholder engagement forums, and innovative funding solutions. The developed framework and study insights have broader applications, offering a model adaptable for other diseases, particularly for neglected tropical diseases, which face similar diagnostic challenges.

The health workforce conundrum for burn care in Uttar Pradesh, India: a qualitative exploration

ABSTRACT Delivering specialised care for major burns requires a multidisciplinary health workforce. While health systems ‘hardware’ issues, such as shortages of the healthcare workforce and training gaps in burn care are widely acknowledged, there is limited evidence around the systems ‘software’ aspects, such as interest, power dynamics, and relationships that impact the healthcare workforce performance. This study explored challenges faced by the health workforce in burn care to identify issues affecting their performance. Qualitative in-depth interviews were conducted with a purposively selected sample (n = 31, 18 women and 13 men) of various cadres of the burn care health workforce in Uttar Pradesh, India. Inductive coding and thematic analysis identified three major themes. First, the dynamics within the multidisciplinary team where complex relations, power and normative hierarchy hampered performance. Second, the dynamics between health workers and patients due to the clinical and emotional challenges of dealing with burn injuries and multitasking. Third, dynamics between specialised burn units and broader health systems are narrated in challenges due to inadequate first response and delayed referral from primary care facilities. These findings indicate that burn care health workers in India face multiple challenges that need systemic intervention with a multipronged human resource for health framework.

How Can Community Data Be Leveraged to Advance Primary Health Care? A Scoping Review of Community-Based Health Information Systems.

Community-based health information systems (CBISs) can provide critical insights into how community health systems function, and digitized CBISs may improve the quality of community-level data and facilitate integration and use of CBISs within the broader health system. This scoping review aims to understand how CBISs have been implemented, integrated, and used to support community health outcomes in low- and middle-income countries (LMICs). Both peer-reviewed and gray literature were included; relevant articles were identified using key terms and controlled vocabulary related to community/primary health care, health information systems, digital health, and LMICs. A total of 11,611 total records were identified from 5 databases and the gray literature. After deduplication, 6,985 peer-reviewed/gray literature were screened, and 95 articles/reports were included, reporting on 105 CBIS implementations across 38 countries. Findings show that 55% of CBISs included some level of digitization, with just 28% being fully digitized (for data collection and reporting). Data flow from the community level into the health system varied, with digitized CBISs more likely to reach national-level integration. National-level integration was primarily seen among vertical CBISs. Data quality challenges were present in both paper-based and digitized CBISs, exacerbated by fragmentation of the community health landscape with often parallel reporting systems. CBIS data use was constrained to mostly vertical and digitized (partially or fully) CBISs at national/subnational levels. Digitization can play a pivotal role in strengthening CBIS use, but findings demonstrate that CBISs are only as effective as the community health systems they are embedded within. Community-level data are often not being integrated into national/subnational health information systems, undermining the ability to understand what the community health needs are. Furthermore, stronger investments within community health systems need to be in place broadly to reduce fragmentation and provide stronger infrastructural and systemic support to the community health workforce.

Exploring paramedic perspectives on emergency medical service (EMS) delivery in Alberta: a qualitative study.

Emergency Medical Services (EMS) in Alberta are facing critical challenges. This qualitative study aims to describe and understand the frontline perspective regarding system level issues and propose provider-informed policy recommendations. 19 semi-structured one-on- one interviews were conducted with Primary or Advanced Care Paramedics (PCP/ACP) across Alberta. Participants were asked to share their perspectives, experiences and recommendations in relation to EMS response times and the working environment. Interviews were analyzed using thematic analysis to identify themes and subthemes. Two core themes were identified as areas of concern: poor response times and the EMS working environment, which each influence and impact the other. Within response times, paramedics highlighted specific difficulties with ED offloading, a lack of resources, low-acuity calls, and rural challenges. In terms of the EMS working environment, four subthemes were apparent including attrition, unhealthy culture, organizational barriers and the need for paramedic empowerment. Providers made many recommendations including creating and expanding emergency mobile integrated health (MIH) branches, sharing 811 and 911 responses, and enforcing ED target offload times amongst other suggestions. While response times are a key and highly visible problem, there are many critical factors like the EMS working environment that degrade patient care and cause concern amongst frontline practitioners. Multifaceted policy changes are to be explored to reduce disfunction within EMS services, enhance the well-being of the workforce and deliver improved patient care. Specific EMS-oriented policies are important for moving forward to reduce transfers to EDs, but the broader health system which is over capacity is causing downstream effects into EMS must be addressed by government and health administrators.

Learning from the End of the Public-Private Partnership for Lesotho's National Referral Hospital Network.

Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP. We assessed successes and challenges to performance of the QMMH-IN PPP. We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility. The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

Key Learnings from the Development and Early Use of Global Guidance on the Integration of COVID-19 Vaccination into Broader Health Systems.

More than 13.5 billion COVID-19 vaccine doses were delivered between 2021 and 2023 through a mix of delivery platforms, with mass vaccination campaigns being the main approach. In 2022, with the continued circulation of SARS-CoV2 and the need for periodic boosters being most likely, countries were required to plan for more sustainable approaches to provide COVID-19 vaccinations. In this context of uncertainty, a global tool for integrating COVID-19 vaccines into immunization programs and as part of broader health systems was published jointly by the WHO and UNICEF to respond to country needs. This paper summarizes the approach to, and lessons learned during, the development of a global guidance document and describes some examples of its early use in low- and middle-income countries (LMICs). The guidance leveraged existing health system frameworks, proposed four steps for planning and implementing the COVID-19 vaccination integration journey, and identified investment areas. The development process maximized robust global stakeholder and country engagement, and the timeframe was aligned with donor funding windows to support countries with the integration of COVID-19 vaccination. The rapid dissemination of the guidance document allowed countries to ascertain their readiness for integrating COVID-19 vaccination and inform the development of national plans and funding applications. While progress has been made in specific areas (e.g., optimizing cold chain and logistics leveraging COVID-19 vaccination), in the context of decreasing demand for COVID-19 vaccines, reaching adult COVID-19 vaccine high-priority-use groups and engaging and coordinating with other health programs (beyond immunization) remain challenges, particularly in LMICs. We share the learning that despite the uncertainties of a pandemic, guidance documents can be developed and used within a short timeframe. Working in partnership with stakeholders within and beyond immunization towards a common objective is powerful and can allow progress to be made in terms of integrating health services and better preparing for future pandemics.

Poor policy and inadequate regulation of medical technology is driving low-value care in Australia's private health system.

Millions of Australians use the private health system every year. They should receive safe, high-quality, value-based care. However, poor policy and inadequate regulation of medical technology is driving low-value care at great expense to consumers and the broader health system. Key drivers include the Prescribed List of Medical Devices and Human Tissue, gaps in quality and safety controls for devices being used, and marketing and conflicts of interest. All of these should be addressed to reduce low-value care in Australia's private health system, so consumers are protected from harm and limited health budgets are used effectively.

Assessing primary healthcare disaster preparedness: a study in Northern Italy.

The aim of this paper is to outline the steps taken to develop an operational checklist to assess primary healthcare (PHC) all-hazards disaster preparedness. It then describes a study testing the applicability of the checklist. A PHC approach is an essential foundation for health emergency and disaster risk management (H-EDRM) because it can prevent and mitigate risks prior to disasters and support an effective response and recovery, thereby contributing to communities' and countries' resilience across the continuum of the disaster cycle. This approach is in line with the H-EDRM framework, published by the World Health Organization (WHO) in 2019, which emphasizes a whole-of-health system approach in disaster management and highlights the importance of integrating PHC into countries' H-EDRM. Nevertheless, literature focusing on how to practically integrate PHC into disaster management, both at the facility and at the policy level, is in its infancy. As of yet, there is no standardized, validated way to assess the specific characteristics that render PHC prepared for disasters nor a method to evaluate its role in H-EDRM. The checklist was developed through an iterative process that leveraged academic literature and expert consultations at different stages of the elaboration process. It was then used to assess primary care facilities in a province in Italy. The checklist offers a practical instrument for assessing and enhancing PHC disaster preparedness and for improving planning, coordination, and funding allocation. The study identified three critical areas for improvement in the province's PHC disaster preparedness. First, primary care teams should be more interdisciplinary. Second, primary care services should be more thoroughly integrated into the broader health system. Third, there is a notable lack of awareness of H-EDRM principles among PHC professionals. In the future, the checklist can be elaborated into a weighted tool to be more broadly applicable.

"We help people change harmful norms": Working with key opinion leaders to influence MNCH+N behaviors in Nigeria.

Nigeria's Maternal, newborn, and child health and nutrition (MNCH+N) outcomes rank among the world's poorest. Engaging traditional and religious leaders shows promise in promoting related behaviors. The Breakthrough ACTION/Nigeria project worked with leaders in northern Nigeria to implement the Advocacy Core Group (ACG) model, a social and behavior change (SBC) approach aimed at influencing community norms and promoting uptake of MNCH+N behaviors. Qualitative assessment of the model contributes to evidence on SBC approaches for enhancing integrated health behaviors. This qualitative study was conducted in Nigeria's Bauchi and Sokoto states in May 2021. It involved 51 in-depth interviews and 24 focus group discussions. The study was grounded in the social norms exploration (SNE) technique to examine normative factors influencing behavior change within the ACG model context. Data analysis used a reflexive thematic analysis approach. Ethical approvals were received from all involved institutions and informed consent was obtained from participants. The ACG model was vital in the uptake of MNCH+N behaviors. The influence of ACG members varied geographically with greater impact observed in Sokoto State. Normative barriers to improving MNCH+N outcomes included perceived religious conflicts with family planning, preference for traditional care in pregnancy, misinformation on exclusive breastfeeding (EBF), and gender-based violence resulting from women's decision-making. The study demonstrated positive progress in norm shifting, but EBF and GBV norms showed slower changes. Broader challenges within the health system, such as inadequate services, negative attitudes of healthcare providers, and workforce shortages, hindered access to care. The ACG model increased awareness of health issues and contributed to potential normative shifts. However, slower changes were observed for EBF and GBV norms and broad health system challenges were reported. The model appears to be a promising strategy to further drive SBC for better health outcomes, especially where it is combined with supply-side interventions.

Facilitating access to primary care for people living in socio-economically vulnerable circumstances in Belgium through community health workers: towards a conceptual model

IntroductionInspired by examples in low- and middle-income countries, 50 community health workers (CHWs) were introduced in Belgium to improve access to primary care for people living in socio-economically vulnerable circumstances. This article aims to explore the ways in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care.MethodsThe qualitative research focuses on the first year of implementation of this pioneer nationwide CHW programme in Belgium. To respond to the research aim, thirteen semi-structured in-depth interviews were held with people living in socio-economically vulnerable circumstances. In addition, a photovoice study was conducted with fifteen CHWs comprising four phases: (1) photovoice training; (2) participatory observation with each CHW individually; (3) an individual semi-structured in-depth interview; and (4) three focus group discussions. The transcripts and the observation notes were analysed in accordance with the abductive analysis procedures described by Timmermans and Tavory.ResultsThe qualitative results show that the CHWs’ outreaching way of working allows them to reach people living at the crossroads of different vulnerabilities that are intertwined and reinforce each other. They experience complex care needs, while at the same time they face several barriers that interrupt the continuum of access to primary care – as conceptualised in the theoretical access-to-care framework of (Levesque et al. Int J Equity Health. 12:18, 2013). Building on the theoretical access-to-care framework described by (Levesque et al. Int J Equity Health. 12:18, 2013), the conceptual model outlines first the underlying mechanisms of CHW-facilitated access to primary care: (I) outreaching and pro-active way of working; (II) building trust; (III) providing unbiased support and guidance in a culturally sensitive manner; and (IV) tailoring the CHWs’ approach to the unique interplay of barriers at the individual and health system level along the access-to-care continuum as experienced by the individual. Further disentangling how CHWs provide support to the barriers in access to care across the continuum and at each step is outlined further in the process characteristics of this conceptual model. Furthermore, the qualitative results show that the way in which CHWs support people is also impacted by the broader health system, such as long waiting times and unwelcoming healthcare professionals after referral from a CHW.DiscussionThe conceptual model of CHW-facilitated access to primary care developed in this article explores the way in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care in Belgium. Through their outreaching method, they play a valuable bridging role between the Belgian healthcare system and people living in socio-economically vulnerable circumstances.

Assessing the contribution of hospital medicine patients to the tertiary quaternary care mission of an academic medical center.

Academic medical centers must balance caring for patients in their community with their role as referral centers for more profitable tertiary quaternary (T/Q) care. Hospital medicine services, which admit patients largely from the emergency department, often have the lowest proportion of T/Q care and may thus be under pressure to demonstrate their value to the health system. Looking at the 5771 patients that were discharged from our hospital medicine service between 2021 and 2022, we found that three quarters (74.6%) of patients had at least one prior outpatient encounter at our institution, and that more than a third (36.1%) were established patients in departments of strategic importance to our institution. Our study provides a framework for academic hospital medicine services looking to assess their patient population's connection with the broader health system and suggests that our hospital medicine service provides inpatient care to a population critical to the role of the institution in our community both locally and regionally.

Increasing Access to Contraception: Examining Barriers and Facilitators of Long-Acting Reversible Contraception.

Objective(s): To identify barriers and facilitators related to reimbursement processes, device acquisition costs, stocking, and supply of long-acting reversible contraception (LARC) from 27 jurisdictions (26 states/1 territory) participating in the Increasing Access to Contraception Learning Community from 2016 to 2018. Materials and Methods: A descriptive study using qualitative data collected through 27 semistructured key informant interviews was conducted during the final year of the learning community among all jurisdictional teams. Excerpts were extracted and coded by theme, then summarized as barriers or facilitators using implementation science methods. Results: Most jurisdictions (89%) identified barriers to reimbursement processes, device acquisition, stocking, and supply of LARC devices, and 85% of jurisdictions identified facilitators for these domains. Payment methodology challenges and lack of billing and coding processes were identified as the most common barriers to reimbursement processes. Device acquisition cost challenges and lack of delivery facility protocols for billing were the most common barriers to device acquisition, stocking, and supply of LARC. The most common facilitator of reimbursement processes was expanded payment methodology options, whereas supplemental funding for acquisition costs and protocol development were identified as the most common facilitators of device acquisition, stocking, and supply. Conclusion: Revised payment methodologies and broader health systems changes including additional funding sources and protocols for billing, stocking, and supply were used by learning community jurisdictions to address identified barriers. The learning community framework offers a forum for information exchange, peer-to-peer learning, and sharing of best practices to support jurisdictions in addressing identified barriers and facilitators affecting contraception access.